Cycle 1
Health 2024-08-23 · Fire 2024-08-23
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Tulsa, OK
Leisure Village Health Care Center
2-star overall rating with 2-star inspections with 12 recent health deficiencies
2154 South 85th East Avenue, Tulsa, OK
(918) 622-4747
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Mgm Healthcare
Operator or chain grouping
Approved since
1995-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
30 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.14
Registered nurse staffing · state 0.34 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.92 · national 0.87
Aide hours / resident day
2.65
Nurse aide staffing · state 2.57 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.84 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.27 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.49 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.29 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.03 · national 0.07
Adjusted RN hours
0.13
CMS adjusted RN staffing hours
Adjusted total hours
3.58
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 55% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 56% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,941
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.11
Baseline 19.25% · Performance 20.92% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Healthcare-associated infections
1.35
Baseline 8.41% · Performance 7.78% · Measure score 1.35 · Achievement 0 · Improvement 1.35
Total nurse turnover
0
Baseline 71.43% · Performance 71.59% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.35
Baseline 3.36 hours · Performance 3.46 hours · Measure score 1.35 · Achievement 1.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.79% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 13.11% · Lower 95% interval 6.89% |
| Discharge to community | 29.33% |
50.57%
21.2 pts worse
|
Worse than the National Rate · Eligible stays 25 · Observed rate 8% · Lower 95% interval 16.63% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.78% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 4.18% |
| Staff COVID-19 vaccination coverage | 13.4% |
8.2%
5.2 pts better
|
Numerator 13 · Denominator 97 |
| Staff flu vaccination coverage | 2.16% |
42%
39.8 pts worse
|
Numerator 3 · Denominator 139 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.9
1.3 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.5% |
90.3%
19.8 pts worse
|
93.4%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.4% · Q2 74.7% · Q3 69.4% · Q4 57.1% · 4Q avg 70.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.6% |
94.6%
8 pts worse
|
95.5%
8.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
4.5%
2.9 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 1.4% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
3.3%
5.3 pts worse
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.7% · Q3 12.7% · Q4 10.8% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 1.1% |
3.6%
2.5 pts better
|
5.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 1.6% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
25.3%
0.3 pts better
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 23.1% · Q3 29.7% · Q4 31.2% · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
18.6%
10.7 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 4.0% · Q3 7.7% · Q4 16.1% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 4.5% |
15.5%
11 pts better
|
16.3%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 15.6% · Q3 0.0% · Q4 2.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.6% |
14.1%
8.5 pts better
|
14.9%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 12.9% · Q3 1.6% · Q4 4.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.1%
2.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.8%
2.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
17.8%
8 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 21.1% · Q3 37.9% · Q4 19.7% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
5.1%
2.6 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.2% · Q3 0.0% · Q4 3.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 19.7% |
75.0%
55.3 pts worse
|
81.7%
62 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 18.4% · Q3 13.0% · Q4 24.0% · 4Q avg 19.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.2% |
17.1%
8.9 pts better
|
12.0%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.2% · Observed 12.0% · Expected 16.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.2% |
74.0%
39.8 pts worse
|
79.7%
45.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.4% |
27.0%
8.6 pts better
|
23.9%
5.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.4% · Observed 24.0% · Expected 31.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
16 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2020-03-05 · Fire 2020-03-05
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2020-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-18
E · Potential for more than minimal harm
2020-03-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-03-18
E · Potential for more than minimal harm
2020-03-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-03-18
E · Potential for more than minimal harm
2020-03-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2026-01-28
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2026-03-05
E · Potential for more than minimal harm
2026-01-28
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2026-03-05
E · Potential for more than minimal harm
2026-01-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-03-05
E · Potential for more than minimal harm
2025-09-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-04-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-11
D · Potential for more than minimal harm
2024-09-23
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-08-23
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-23
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-23
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-07-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-07-03
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-07-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-19
D · Potential for more than minimal harm
2024-06-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-19
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-14
D · Potential for more than minimal harm
2024-06-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-14
D · Potential for more than minimal harm
2023-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-07-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-06
E · Potential for more than minimal harm
2023-07-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-07-20
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-09-06
F · Potential for more than minimal harm
2020-03-05
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-04-08
E · Potential for more than minimal harm
2020-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-08
D · Potential for more than minimal harm
2020-03-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-04-08
D · Potential for more than minimal harm
2020-03-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-04-08
Penalties and ownership
What sits behind the stars
$0
2024-06-19
Payment Denial
Payment Denial · denial start 2024-09-19 · 7 days
7 day denial
Ownership
Jeremias, Baruch
5% Or Greater Direct Ownership Interest · Individual
Bienstock, Judah
5% Or Greater Direct Ownership Interest · Individual
Mls Acquisition LLC
5% Or Greater Direct Ownership Interest · Organization
Schreiber, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Fitch, Stephen
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Tulsa Nursing Center
Tulsa, OK
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Emerald Care Center Tulsa
Tulsa, OK
1-star overall rating with 1-star inspections with Special Focus status with $91,783 in total fines with 25 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Gracewood Health & Rehab
Tulsa, OK
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out